What is the recommended dosing for paracetamol (acetaminophen)?

Recommended Dosing for Paracetamol (Acetaminophen)

The standard adult dose of paracetamol is 1000 mg every 6-8 hours, with a maximum daily dose of 3000-4000 mg, though a more conservative maximum of 3000 mg daily is increasingly recommended to ensure safety. 1

Standard Adult Dosing

• Regular dose: 1000 mg every 6-8 hours 1, 2
• Maximum daily dose: 4000 mg (not exceeding 6 doses in 24 hours) 3, 2
• Conservative maximum daily dose: 3000 mg 1
• Duration: For pain, do not use for more than 10 days without medical supervision 3
• Duration: For fever, do not use for more than 3 days without medical supervision 3

Special Population Considerations

Patients with Liver Disease

• Patients with liver cirrhosis: 2000-3000 mg daily maximum 4, 1
• Contraindicated in patients with liver failure 1
• No dose reduction typically needed for patients with chronic, benign liver disease 2

Elderly Patients

• Start with lower doses and titrate as needed 1
• No routine dose reduction is required based solely on age 5

Patients with Renal Insufficiency

• No dose adjustment typically necessary in chronic renal insufficiency 2
• Paracetamol is the non-opioid analgesic of choice in patients with chronic renal insufficiency 2

Pediatric Dosing

• 15 mg/kg every 4 hours, up to a total of 60 mg/kg/day 2

Administration Routes and Formulations

• Oral, intravenous, or rectal routes available 2
• Effervescent tablets provide more rapid absorption and onset of action than conventional tablets 2

Safety Considerations and Warnings

Liver Toxicity Risk Factors

• Exceeding the maximum daily dose (>4000 mg/day) 3
• Concomitant use with other medications containing acetaminophen 3
• Alcohol consumption (3 or more alcoholic drinks daily) 3
• Fasting states 6

Monitoring

• Monitor liver function in patients receiving regular paracetamol at maximum doses 1
• Be vigilant for signs of liver damage, especially in high-risk patients 3

Drug Interactions

• Low risk of drug interactions due to minimal plasma protein binding 2
• Consult a healthcare provider before use if taking warfarin 3

Pain Management Algorithm

1. For mild to moderate pain:

   • Start with paracetamol 1000 mg every 6-8 hours
   • Do not exceed 4000 mg daily (or 3000 mg for conservative approach)

2. For moderate pain with inadequate response:

   • Consider adding NSAIDs if not contraindicated 4
   • Or consider weak opioids (e.g., codeine, tramadol) 4

3. For severe pain:

   • Consider strong opioids in addition to paracetamol 4

Common Pitfalls to Avoid

• Unintentional overdose due to multiple products containing acetaminophen 3
• Exceeding recommended dosing frequency (more than 6 doses in 24 hours) 3
• Prolonged use without medical supervision (>10 days for pain, >3 days for fever) 3
• Failure to recognize early signs of hepatotoxicity (nausea, vomiting, abdominal pain) 4
• Alcohol consumption while taking paracetamol, which increases hepatotoxicity risk 3

Paracetamol remains a first-line analgesic for mild to moderate pain due to its favorable safety profile when used appropriately, especially compared to NSAIDs which carry greater gastrointestinal, renal, and cardiovascular risks 5.